Abstract

Background

Postnatal depression has received considerable research and clinical
attention, however anxiety and stress in the postpartum has been relatively
ignored. Along with the widespread use of the Edinburgh Postnatal Depression
Scale (EPDS), depression has become the marker for postnatal maladjustment.
Symptoms of anxiety tend to be subsumed within diagnoses of depression, which
can result in anxiety being minimized or overlooked in the absence of
depression. Some researchers have identified the need to distinguish between
postnatal depression and anxiety, and to discern cases where depression and
anxiety co-exist. The aim of this study was to assess the prevalence of
postnatal distress using the EPDS and the Depression Anxiety Stress Scales
(DASS-21).

Method

As part of a larger cross-sectional study, the EPDS and DASS-21 were
administered to a convenience sample of 325 primiparous mothers, who ranged in
age from 18 to 44 years (M = 32 years). Recruited through mother's groups and
health centres in Melbourne Australia,
inclusion was limited to mothers whose babies were aged between 6 weeks and 6
months. Analyses included comparisons between the classifications of women
according to the EPDS and the DASS-21, and an exploration of the extent to
which the EPDS identified anxious-depressed women.

Results

The EPDS identified 80 women (25%) as possibly depressed (using a cut-off of
over 9), of which the DASS-21 corroborated 58%. In the total sample, 61 women
(19%) were classified by the DASS-21 to be depressed. Using broader criteria
for distress, it was revealed by the DASS-21 that a further 33 women (10%)
showed symptoms of anxiety and stress without depression. A total of 41 women
(13%) had symptoms of anxiety either in isolation or in combination with
depression. The DASS-21 identified 7% of the sample as being both anxious and
depressed. This at-risk sub-group had higher mean EPDS and DASS-depression
scores than their depressed-only counterparts.

Conclusion

The prevalence of anxiety and stress in the present study points to the
importance of assessing postnatal women for broader indicators of psychological
morbidity than that of depression alone. The DASS-21 appears to be a useful
instrument for this purpose.

Anti-Choice Woman-Hating Goes Mainstream

She consented in the murder of an unborn child. There are some
situations where the mother may in fact die along with her child [13].

With this brief quote, the speaker, the Rev. John Ehrich, medical ethics
director for the Diocese of Phoenix, deserves credit for achieving a twofer in
a recently revived (if not formally declared) misogyny competition that is now
sweeping the anti-choice world. He is not only stating that a gravely ill
woman (the mother of four children) should have been left to die, rather than
being permitted an abortion; he is also explaining why Sister Mary Margaret
McBride, the nun-administrator of a Catholic hospital who authorized the
abortion (thereby saving the woman’s life) deserves to be excommunicated.

This case, which has received wide coverage in RH Reality
Check[14] and other media,
has predictably stunned many people, across the abortion divide. Some have
pointed out that the Phoenix
diocese misinterpreted Catholic health care directives, and that abortion is
permissible under these rules when a woman’s life is at stake. Others have made
the common sense observation that if the woman had died, not only would her
four children remain motherless, but the 11-week old fetus would not have
survived either. Inevitably, some commented on the disparity between the nun’s
swift excommunication and the fact that none of the identified pedophile
priests have received such punishment.

But while the Phoenix
case may cause the most jaw-dropping, with its undisguised preference for a
woman’s death over an abortion, there are other recent instances that similarly
suggest an upsurge of blatant woman-hating in the antiabortion world. Take the
notorious Utah
law [15] passed earlier this year in response
to the deeply sad case of a pregnant teenager who paid a stranger to beat her
in the hope of inducing a miscarriage. (In spite of the severe beating that
occurred, the pregnancy resulted in a live birth). Outraged that the male in
question received a jail sentence but that there was no legal mechanism with
which to charge the teen, a Utah
legislator pushed through legislation that criminalizes the seeking of an
illegal abortion, and which many observers believe has the practical effect of
making all miscarriages in the state theoretically suspect. Had this law been
in effect at the time of the incident described above, and had the fetus not
survived, the desperate young woman could have received fifteen years to life.
As the untroubled sponsor of the bill told a reporter, the young woman
“has to face the consequences of her barbaric actions.” [16] No one stopped to ask under what conditions
she had gotten pregnant nor why she took such drastic measures.

Then there are the mandatory ultrasound laws. These are occurring in a
number of state legislatures, but nowhere to date with such viciousness as the one
recently passed in Oklahoma.
[17] There the new law stipulates that one
hour before her abortion, the patient must receive an ultrasound, with the
monitor positioned so that she can see it, and the doctor must point to and
describe the heart, limbs and organs of the fetus. There are no exceptions
for victims of rape or incest.

The current Supreme Court has also shown an unprecedented and disturbing
hostility to women with respect to abortion. In its most recent decision on the
subject, the 2007 Gonzales v Carhart case [18]
which upheld a ban on a certain abortion technique (intact dilation and
extraction, or so-called “partial birth abortion”), the Court, shockingly, for
the first time upheld an abortion restriction which did not allow any exception
for a woman’s health.

Do these examples of misogyny represent anything new? To be sure, in some
extremist anti-choice circles, full throated woman-hating never went away.
(See, for example, this video [19] from
several years ago of Flip Benham screeching at women entering a N. Carolina clinic that “Satan will drink the blood of
your child!”) But in other, more mainstream quarters of the movement, the
heated, and hateful rhetoric of the period immediately after Roe—where women
seeking abortion were routinely called “sluts” and “baby killers” —gradually
became replaced by a new frame: abortion hurts women. Given that by the
early 1980s, about 40 percent of American women were estimated to have an
abortion during their reproductive years (the number now is about 33 percent),
arguably such hate speech was counterproductive for the opponents of abortion:
too many Americans either themselves had had an abortion or knew someone who
did. Thus, antiabortion rhetoric shifted to professed sympathy for women, and
abortion providers—those doing the hurting—became the main objects of
demonization.

The nature of laws restricting abortions has also undergone changes in the
recent past, reflecting a heightened mean-spiritedness. While all such laws
have as their goal the objective of making the procedure more difficult to
obtain, earlier laws—for example, the waiting periods, or the TRAP laws [20] governing minute, arguably irrelevant physical
features of freestanding clinics-- these measures did not have quite the same
blatant cruelty as current measures do, given the mandates to force a woman to
hear a description of her ultrasound or to be told terrifying lies about
supposed links between abortion and breast cancer, suicide and infertility, as
is required in a number of states. [20]

Why has this increase in undisguised misogyny occurred? Certainly part
of the answer is the election of Barack Obama. Like other sectors of the
rightwing, the antichoice movement has been both enraged and energized by the
Obama presidency. There not only has been a change in rhetoric and in the
quantity and quality of abortion legislation since the 2008 election, but also
an upsurge in aggression and violence at the site of clinics themselves (though
most of this violence to date has been directed at providers, rather than patients,
as we saw with the tragic murder of Dr. Tiller one year ago).

Another explanation lies in the considerable success the antichoice movement
has had in stigmatizing abortion, and therefore those who both receive
abortions and provide them. As the overall number of abortion patients
drop, and as poor women of color disproportionately comprise the population of
abortion patients, [21] it has become far
easier for mainstream actors in the antichoice movement to see a split world,
in which good women do the “right thing” when faced with an unwanted pregnancy
and bad women don’t. This deeply stigmatized view of abortion
recipients enables the “respectable” opponents of abortion—the legislators, the
Church officials and so on—to go a rhetorical place where their extremist
colleagues have always been.

Response to the Government White
Paper ‘Equality and Excellence: liberating the NHS’, from the organisation
‘electivecesarean.com’.

electivecesarean.com hopes that this government will listen to and act on the views of a
diverse range of maternity support groups in response to this White Paper, and
understands (as it appears to, in a most welcome goal of ‘extending choice’)
that women are not homogeneous creatures, and that they (and their babies) are
not best served by a blanket ‘one size fits all’ approach to maternity care.
Choice about how they give birth (e.g. planned caesarean versus trial
of labour) is as important as where they birth (e.g. at hospital or
home), and with whom (e.g. consultant versus midwifery-led care).

Furthermore, electivecesarean.com
wishes to highlight grave concerns about current drives to reduce ‘low risk’
planned caesareans, and indeed to reduce caesarean rates according to
percentage targets that have no basis in evidence. Choice aside, the lives of
women and babies are being put at risk in many hospitals where the emphasis is
on ‘normal/spontaneous delivery at all costs’. The delay and/or failure to
carry out necessary caesarean deliveries are not placing the health
and wellbeing of families first, but moreover, are an entirely misdirected and
misinformed effort to reduce NHS costs.

The fact is that unsuccessful planned
vaginal deliveries – not planned caesarean deliveries – are costing the
NHS billions of pounds in litigation costs. Yet these huge sums of money are
never attributed to the relevant birth plan. And neither are the short- and
long-term costs associated with the healthcare (physical and psychological) of
women and babies who are injured during actual and attempted vaginal deliveries.
Some women for example go on to have numerous operations to repair
the damage caused during these births. electivecesarean.com
proposes that all future allocating and accounting for NHS maternity resources
should factor in these realities of cost. They should no longer be ignored or
avoided.

Electivecesarean.com does not propose that planned surgery be presented to
women as risk-free (no birth plan is), but rather, that it is
presented as a legitimate birth plan for informed and educated women following
an individualized consultation. That said, as the White Paper states, ‘not
all choices will be appropriate or safe for all women’, which is entirely true,
but for those whom it is appropriate and safe, it should not be
refused – and most certainly not on grounds of fiscal policy or
rate-driven targets (since both of these arguments against planned caesarean
delivery are fundamentally flawed).

Finally, in support of this White Paper
response, the information below is included for your review please. It is part
of an original submission by electivecesarean.com
to NICE during its Scope consultation earlier this year for the Caesarean
Section (Update). It contains a number of important study references and
articles that support the statements by electivecesarean.com above,
and can be read in full via the pdf link provided. Please note that since the
time of this submission, NICE has confirmed that ‘maternal request’ will now be
included in its review of the Caesarean Guideline.

Thank you for accepting my response and I
look forward to future positive developments in NHS maternity care, where the
physical and psychological health outcomes of families are placed ahead of any
single birth plan ideology, and where genuine autonomy – not arbitrary targets
– are what count.

ADDITIONAL INFORMATION IN
SUPPORT OF THIS RESPONSE

As seen in the National Institute for
Health and Clinical Excellence - Caesarean Section (Update) Scope Consultation
Table (24 February - 24 March 2010) - http://www.nice.org.uk/nicemedia/live/12156/49682/49682.pdf

Electivecesarean.com stated:

(On Cost:)

Appendix C of the 2004 NICE guideline
reads: ‘The estimated cost of maternal request can change depending on the cost
value entered in the model... If the lowest vaginal birth costs reported in the
review and highest caesarean cost reported in the view are used, the additional
cost for accepting 8,747 maternal requests for caesarean is around £21.2m.
[But] since the highest cost for vaginal birth in the review is higher than the
lowest cost for caesarean, if these values were entered into the model, the
model would show that increasing planned caesarean due to maternal request
would lead to savings, which is not a realistic conclusion.’ This is an
incredible admission in the compilation of caesarean cost statistics - that we
can only accept the conclusion if it is the conclusion we expect or endorse.
Again, this area of the guideline in relation to maternal request and cost is
in urgent need of review.

On the subject of cost, I can provide other
quotes and studies, but as one example, in 2008, an ACOG Committee Opinion
concluded that it ‘is not clear whether widespread implementation of elective
cesarean birth would increase or decrease resources required to provide
delivery services.’ (http://www.acog.org/from_home/publications/ethics/co395.pdf)

Finally, it is important to note that
current cost comparisons are flawed in terms of maternal request, as they
contain medical and/or emergency surgical costs, but more crucially, vaginal
delivery costs repeatedly fail to include the financial impact of:

2. short and long-term perineal and pelvic
floor repair (e.g. prolapse) and counselling when trauma occurs.

3. huge litigation bills when vaginal
delivery goes wrong and a baby/mother is injured or dies. For NICE to discount
the cost of litigation to the NHS when it comes to evaluating the cost of
maternal request versus trial of labour is a colossal error of judgement, and I
would urge a reconsideration of this issue.

(On caesarean rates and targets:)

It needs to be recognised that rising
caesarean rates are no longer inherently viewed as a ‘bad’ thing; it is not the
rate that is important, but rather, positive birth outcomes for mothers and
babies. Also, any attempt to reduce rates should focus on those that are
‘unwanted’ and not those that are ‘wanted’.

It is vital to note that the WHO
recommendation of 1985 (that caesarean rates should be limited to 10-15%) has
been updated as of its 2009 Handbook (which was not publicised and very few
people seem to be aware of it). The WHO now admits that there is no empirical
evidence for its 25-years-old recommended figure, and that there is in fact no
known optimum rate. More info can be found here: http://www.medicalnewstoday.com/articles/169058.php

(On informed choice:)

There is also an issue of morbidity
tolerance for women; some will prefer abdominal morbidity in preference to
perineal or pelvic floor morbidity – for example, the 2003 U.S. Healthgrades nationwide
survey of hospitals uncovered significantly higher than expected vaginal
complication rates in hospitals with lower than expected caesarean rates, and
lower than expected vaginal complication rates in hospitals with higher than
expected caesarean rates, ‘suggestive of, but not definitive of, inappropriate
under-utilisation of preplanned first time caesarean deliveries.'

Re: Maternal Request Caesarean will not be
updated. Since the 2004 NICE Guideline, there has been an unprecedented
publication of research studies, surveys and medical opinions on the issue of
maternal request. This surely constitutes ‘changes to the evidence base’ and
means that it should be included in this review.

To begin with, there was the March 2006 NIH
State-of-the-Science Conference Statement: “Cesarean Delivery on Maternal
Request”:

http://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf

While the panel concluded that there 'is
insufficient evidence to evaluate fully the benefits and risks of cesarean
delivery on maternal request as compared to planned vaginal delivery, and more
research is needed', this is largely because there had been no effective
clinical trials to compare the two at that time. However, the panel was able to
conclude that 'any decision to perform a cesarean delivery on maternal request
should be carefully individualized and consistent with ethical principles.'
[*note* In 2003, an ACOG ethics committee stated that it is risks from vaginal
delivery: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=2&DR_ID=20658]

The panel also concluded that due to the
fact that 'the risks of placenta previa and accreta rise with each cesarean
delivery, cesarean delivery on maternal request is not recommended for women
desiring several children.' [*note* The fertility rate in the UK is less than
2, and the vast majority of women requesting a caesarean are only planning 1 or
2 children; therefore, their maternal request is legitimate within these
guidelines.]

The panel also concluded that 'cesarean
delivery on maternal request should not be performed prior to 39 weeks of
gestation or without verification of lung maturity, because of the significant
danger of neonatal respiratory complications.' [*note* Again, if a woman stays
within this guideline, and does not deliver prior to 39 weeks, she should be
allowed to have a caesarean. Furthermore, studies that demonstrate poor
outcomes for babies born via planned casearean delivery prior to this
gestational age should not be used as evidence against maternal request at 39
weeks.]

[NIH background: The National Institutes of
Health (NIH) consensus and state-of-the-science statements are prepared by
independent panels of health professionals and public representatives on the
basis of 1) the results of a systematic literature review prepared under
contract with the Agency for Healthcare Research and Quality (AHRQ), 2)
presentations by investigators working in areas relevant to the conference
questions during a 2-day public session, 3) questions and statements from
conference attendees during open discussion periods that are part of the public
session, and 4) closed deliberations by the panel during the remainder of the
second day and the morning of the third.]

Secondly, there are a large number of
studies that point to better health outcomes for babies born via elective
caesarean delivery at 39 weeks, so why not allow women the opportunity to
choose the safest birth for their baby if that’s their informed conclusion? For
example (note: PCD = planned caesarean delivery):

*Canadian study of almost 40,000 term
deliveries, 1994-2002 comparing outcomes of PCD for breech presentation with
spontaneous labour with anticipated vaginal delivery (i.e. PVD) at term in
pregnancies with a cephalic-presenting singleton. Life-threatening maternal
morbidity was similar in each group. Life-threatening neonatal morbidity was
decreased in the CS group. It concluded that ‘elective pre-labour Caesarean
section...at full term decreased the risk of life-threatening neonatal
morbidity compared with spontaneous labour with anticipated vaginal delivery.'
(Dahlgren et al, 2009)

*Californian study of almost 2m babies born
1999-2003 excl. EGA <38w0d, or >42w6d. [In the knowledge that CDMR is
recommended at 39 weeks EGA:] Infants born beyond 41w0d EGA have greater
neonatal mortality relative to term infants born between 38w0d and 40w6d.
(Bruckner et al, 2008)

*U.S. analysis of Ovid Medline over
the past 10 years incl. intrauterine fetal demise: ‘Copper reported that the
rate of stillbirth is consistent from 23 to 40 weeks EGA with about 5% of all
stillbirths occurring at each week of gestation. Yudkin reported a rate of 0.6
stillbirths per 1000 live births from 33 to 39 weeks EGA. After 39 weeks EGA, a
significant increase in the stillbirth rate was reported (1.9 per 1000 live
births). Fretts reported on fetal deaths per 1000 live births from 37 to 41
weeks of gestational age, showing that the rate progressively increased from
1.3 to 4.6 with each week of gestation. It can be estimated that delivery at 39
weeks EGA would prevent 2 fetal deaths per 1000 living fetuses. This would
translate into the prevention of as many as 6000 intrauterine fetal demises in
the U.S.
annually-an impact that far exceeds any other strategy implemented for

stillbirth reduction thus far.' (Hankins et
al, 2006)

*UK study of 37 of the 873 cases of
intrapartum-related deaths reported in the 1994-1995 national enquiry. ‘When cranial
traumatic injury was observed, it was almost always associated with physical
difficulty at [VD] delivery and the use of instruments. The use of ventouse as
the primary or only instrument did not prevent this outcome. Some injuries
occurred apparently without evidence of unreasonable force, but poorly judged
persistence with attempts at VD in the presence of failure to progress or signs
of fetal compromise were the main contributory factor regardless of which
instruments were used.' (O'Mahony et al, 2005)

*Californian study of 583,340 infants born
to nulliparous women, 1992-1994. The rate of intracranial hemorrhage is higher
among infants delivered by vacuum extraction, forceps, or CD during labor...
the rate among infants delivered by CD before labor is not higher, suggesting
that the common risk factor for hemorrhage is abnormal labor. (Towner et al,
1999)

*U.S. analysis of Ovid Medline over the
past 10 years found that ‘Overall, the frequency of significant fetal injury is
significantly greater with VD, especially operative VD, than with CD for the
nonlaboring woman at 39 weeks EGA or near term when early labor has been
established... infants born to nonlaboring women delivered by CD had an 83%
reduction in the occurrence of moderate or severe encephalopathy' and brachial
plexus palsy with VD ranges from 0.047% to 0.6% compared with CD 0.0042% to
0.095%. "It is reasonable to inform the pregnant woman of the risk of each
of the above categories, in addition to counseling her regarding the potential
risks of a cesarean section for the current and any subsequent pregnancies. The
clinician's role should be to provide the best evidence-based counseling
possible to the pregnant woman and to respect her autonomy and decision- making
capabilities when considering route of delivery." (Hankins et al, 2006)

*England's 2007-08 NHS Maternity Statistics
report that birth injury to scalp occurs in 09% of births (est. as 5,400 babies
in 2004-05, and confirmed that: ‘none related to elective CD.' This breakdown
has not been made available for 2009) (HESonline, 2009)

There is also evidence of better outcomes
for mothers with elective caesarean delivery; again, maternal request allows
women to decide which birth morbidity they find most tolerable – planned
vaginal or planned caesarean:

*Australian retrospective review of 2,212
singleton CDs 2004-5 found that 14 women (0.63%) required a blood transfusion,
and while the ‘risk of blood transfusion for elective and emergency CD are 3.9
per 1000 and 9.8 per 1000', in ‘the absence of risk factors identified in this
study, no women (of a total of 1,293 elective CD) required blood transfusion.'
(Chua et al, 2009)

*UK study of more than 2m women
(CEMACH) >24 weeks EGA found fewer deaths occurred with PCD (n7; 0.31 per
10,000) than any other delivery type. (Treadwell M, BTA, 2008)

*U.S.
study in Massachusetts
1995-2003; risk of maternal death with primary ECD is less than that associated
with VD; also, death directly due to surgery itself is extremely rare (Berger M
and Sachs BP, 2006)

*Australian anonymous postal survey of 78
women who had maternal-request primary CDs in eastern states private maternity
hospitals. Most common reason for CDMR was ‘concerned about risks to the baby'
(46%) and on a scale from 1 (totally unsatisfied) to 10 (completely satisfied),
the mean satisfaction rating reported was 9.25/10. ‘Respondents were highly
satisfied with their delivery'. (Robson et al, 2008)

*Swedish study of CD ‘in the absence of
medical indication' compared 2 groups from 357 healthy primiparas: CDMR (n.91)
and PVD controls (n.266) with 3 self-assessment questionnaires in late
pregnancy, 2 days after delivery and 3 months after birth. ‘After PCD, women
reported a better birth experience compared to PVD women. They were
breastfeeding to a lesser extent 3 months after birth [but] there were no
differences in signs of postpartum depression between the groups 3 months after
birth. (Wiklund et al, 2007)

*Swedish study of women via questionnaires,
incl. 124 emergency CD, 70 ECD, 89 instrumental VD and 96 normal VD. ‘The women
reported more post-traumatic stress reactions following EmCS as well as after
instrumental VD, than after elective CD or normal VD...The psychological
well-being of mothers is generally not so favourable after emergency CD and
instrumental VD, than after elective CD and normal VD. (Ryding EL, 1998)

*UK
observational study at University College Hospital,
London of 102
consecutive women undergoing CD. ‘Women undergoing CD were well informed and
took a considerable part in the decision-making process... High levels of
satisfaction with both the decision and the procedure itself indicate that CD
is an acceptable method of delivery, particularly when an elective procedure.
(Mould et al, 1996)

Tokophobia as an indication for caesarean
delivery can often fall between two stools, and these women are particularly
vulnerable when being forced to have a vaginal delivery. Some doctors view
tokophobia as a medical indication, and permit the ‘maternal request’ on those
grounds while others view it as ‘irrational’ state of mind, controllable with
counselling and/or adequate pain relief during a trial of labour. This 2000
study should be noted and recognised in the discussion on maternal request:

*Queen
Elizabeth Psychiatric
Hospital in Birmingham,
England,
interviews with 26 women ‘noted to have an unreasoning dread of childbirth'.
‘Pregnant women with tokophobia who were refused their choice of delivery
method suffered higher rates of psychological morbidity than those who achieved
their desired delivery method...Close liaison between the obstetrician and the
psychiatrist in order to assess the balance between surgical and psychiatric
2000)

I would add that I am aware of two women
for whom a refusal of maternal request caesarean delivery resulted in their
termination of viable and much-wanted pregnancies.

The maternal request statement in the 2004
NICE guideline, as it stands, is wholly inadequate and open to different
interpretations. I am contacted by numerous women who say that their request is
being denied – including those that have asked for a second referral. I have
also spoken with a number of NHS doctors about this subject, and they confirm
that this is happening – especially in hospitals outside the South East of
England. I have also been told that some doctors do not even write down
‘maternal request’ as an indication for a caesarean because they fear the
repercussions from their NHS Trust; instead, they write down non-existent
medical indications in order to support women that they believe are making a
perfectly legitimate decision. The situation is a mess, and it is not being
helped by the current 2004 maternal request statement.

Finally on this point, some doctors are
speaking out about maternal request, including the very high profile Dr Mark
Porter:

Please note what I have written in the
‘Comments’ section below the main article, and more importantly, Dr Porter’s
positive reaction to what I’ve said.

(On the challenges faced in
establishing the true facts:)

When reviewing caesarean evidence, it is
important to be aware of a bias that exists in some research and reporting on
the subject of maternal request. For example, the recent the recent publication
of a survey by The World Health Organization contained a seriously flawed and
unsubstantiated conclusion in relation to caesarean delivery 'with no
indication', and yet was published in The Lancet and subsequently received mass
media coverage. This is what Nigel Hawkes, director of the pressure group
Straight Statistics wrote about it:

The Department of Health has stopped
publishing the table of birth data that links infant birth injuries with
delivery type, which makes comparative assessment of infant risk extremely
difficult. I noticed this while I was responding to a journalist's request for
information on the incidence of scalp injuries with planned delivery. I knew
that the 2007-08 data (births that occurred in 2004-05) showed that not a
single case occurred with planned elective caesarean sections - and yet scalp
injury as a risk is frequently cited as a serious risk for women who choose
maternal request caesareans. As of 2008-09, this data is no longer available.
Women deserve to know what risks their babies face with different delivery
types, and given the research on babies’ health outcomes cited above, again, I
would reiterate that this is cause to review the 2004 statement on maternal
request.

Table 3.1a on page 22 of the 2004 NICE
guideline is in urgent need of review, and cannot be allowed to stand as it is.
There are a number of out-of-date inaccuracies within the table – most notably
that a woman is 5 times more likely to die with a caesarean. Also, the table
would be of far more value for women planning their births, if it separated
risks into each birth plan’s potential OUTCOME. The overwhelming majority of
emergency caesareans are outcomes of planned vaginal deliveries, and yet this
table mixes these negative surgical outcomes with planned caesarean deliveries
– of which an emergency caesarean is a comparably rare outcome. At the very
least, elective caesareans should command their own column alongside emergency
caesareans and vaginal deliveries.